病案是一种特殊档案。它与其它档案一样具有凭证和参考作用。病案中记载的是患者的健康情况,疾病的发生、发展、诊治经过和医疗效果,在病案中蕴含着大量有价值的信息,这些信息不但能为医院的管理、临床、教学、科研提供帮助,同时也能为医疗保险、伤残鉴定等提供服务。病案信息的利用价值取决于病案的质量,即病历书写的内在质量及首页填写质量。因此,病案 Medical record is a special file. It has the same credentials and reference as any other file. The record shows the patient’s health condition, the occurrence and development of the disease, the diagnosis and treatment, and the medical effect. There are a lot of valuable information in the medical record, which not only can help the hospital’s management, clinical teaching and scientific research, At the same time can also provide medical insurance, disability identification services. The value of medical record information depends on the quality of the medical record, that is, the internal quality of the medical record writing and the quality of homepage filling. Therefore, the medical record